When Should I Worry About...

PODCAST: Snoring Isn't the Only Sleep Apnea Symptom

May 23, 2023


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How do you know if you have sleep apnea? It's common, with estimates suggesting that more than 20% of adults suffer from this sleep-related breathing disorder. Snoring is often assumed to be the primary sleep apnea symptom. But if you don't snore, does that mean you're in the clear? In today's episode, we cover the most common signs of sleep apnea, why it leads to more than just bad sleep and how sleep apnea is diagnosed and treated.

Hosts: Zach Moore (interviewer), Katie McCallum

Expert: Dr. Philip Pirtle, Pulmonologist and Sleep Medicine Specialist

Notable topics covered:

  • There's more to sleep apnea than just snoring
  • The other (potentially more common) sleep apnea symptoms
  • How sleep apnea strains the heart, lungs and more
  • Whether there's a hereditary component to sleep apnea
  • Sleep studies: What to expect and how they aid in sleep apnea diagnosis
  • How the severity of sleep apnea is determined
  • High blood pressure, heart attack, stroke: The consequences of not treating sleep apnea
  • All about CPAP machines, the best way to treat sleep apnea
  • Dr. Pirtle's other tips for alleviating the symptoms of sleep apnea


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Episode Transcript

ZACH: Welcome to On Health with Houston Methodist. I’m Zach Moore. I’m a photographer and editor here, and I’ve worked in multimedia and television for over 15 years - and I’m also a longtime podcaster.

KATIE: I’m Katie McCallum, I’m a former researcher, turned health writer, mostly writing for our blog.

ZACH: Katie, do you snore?

KATIE: I don’t.

ZACH: You don’t?

KATIE: Well, I mean, as much as anybody can be sure they don’t snore, right? ‘Cause like, I’m asleep. I’ve never been told that I snore.

ZACH: Yeah.

KATIE: I have been told on occasion like, “Oh, you were snoring last night.” And it’s usually like if I’m sick or something. Clearly, like, I’m all congested. I’ve been told I’ve snored here and there. But night to night, no I don’t snore.

ZACH: I snore a lot. I’ve been told I snore a lot. So, this particular subject is of great interest to me.

KATIE: Yeah, I think usually, especially, if you’re sleeping in a bed with someone, you know if you snore because the other person is going to let you know.

ZACH: And like you mentioned, you know, if I’m sick or if I’m just exhausted, or if my sleeps way off, and I’m catching up on sleep, I know that I would snore loud. And I think everybody like, can understand or relate to that. But we’re talking like, just random nights where it’s like, if there’s anyone else around, they can’t sleep because you’re snoring so loud. And that’s not always the case with me, but I have been told that maybe it’s maybe happening more than it should.

KATIE: Okay, well. I mean, yeah, if you’re trying to sleep and it’s -- I’m a light sleeper, so I definitely notice when a person is snoring. Sometimes even, you know, I have -- There’s people in my family -- I have family members who snore, and you know, if you’re sharing -- If we go on vacation and we’re sharing a house together and you can hear -- And you can hear it from the other room. Like, I’m a super light sleeper, and I’ll wake up from it. So, yeah, I mean, I think you definitely know if you snore because people will let you know, even people who would try to be nice to be all the time. Which I’d kinda put myself in that category. I’ll still let someone know probably.

ZACH: Well, here you go. Can you go back to sleep after being woken up by someone else snoring?

KATIE: I don’t know, it depends. If I’m like, already, probably in a bit of a stressed state. Like, I’m worried about work, or something going on in my personal life once I’m awake I cannot fall back asleep.

ZACH: You’re one of those, huh?

KATIE: Yeah, no. I’m a super light sleeper.

ZACH: I’m the worst case of that. I’m the person that wakes you up snoring. They wake me up, tells me to go to sleep. I’m like, “Okay, whatever.” And I go back to sleep no problem.

KATIE: You’re right back. Yes.

ZACH: And it’s infuriating to anyone else around.

KATIE: Yeah, exactly. Which makes it another reason why you get told you snore. ‘Cause it’s like, I’m over here suffering, and you’re not suffering, but you’re the problem.

ZACH: Yeah. And so, with snoring, right? You hear loud snoring. You -- People start to think. Okay, what’s causing this, right?

KATIE: Yeah.

ZACH: And sleep apnea seems to be the go-to for a lot of people trying to connect the dots when someone’s snoring loud.

KATIE: Yeah, especially if you’re the partner of a person snoring, and you’re looking for, why are you snoring? Is it something we can fix, in particular. So, it’s like, “Hey, go talk to your doctor about your snoring.” Because yeah, sleep apnea can be a reason for the snoring. Not the only reason though, right, Zach?

ZACH: Right, there is a connection between the two, but one does not necessarily mean the other. And so, that’s what we’re exploring in today’s episode. And we talked to a sleep expert here at Houston Methodist, Dr. Philip Pirtle about it. Let’s get into that conversation.

Alright, we’re here with Dr. Philip Pirtle, who is the Director of Critical Care and Pulmonology here at Houston Methodist Willowbrook. Thank you for being with us today, doctor.

DR. PIRTLE: Thank you very much for having me.

ZACH:  And some of what you specialize in is sleep studies, correct?

DR. PIRTLE: That’s correct. So, I am board certified in pulmonary medicine and critical care medicine, and sleep medicine. A lot of what we do in sleep medicine relates to pulmonary because they both revolve around breathing.

ZACH:  And we’ll be talking a lot about that on today’s conversation because our subject is Sleep Apnea. Now, sleep apnea, I think it’s something that a lot of people know the term, could you define for us what exactly is sleep apnea. When someone says, “Oh, I have sleep apnea.” What is happening to them?

DR. PIRTLE: Apnea is a term that is derived from Greek actually, where the words "A" -- "Pnea" -- Or pnea just means breath or air. So, the term Apnea means “no air.” So, literally what it means is there're interruptions in breathing, or short pauses in breathing, and in the context of sleep, these pauses happen while sleeping. Now, sleep apnea is a complex in that it can be either central apnea, or it can be obstructive apnea. What most people mean when they say, "Sleep apnea," is obstructive sleep apnea. It is by far the most common sleep disordered breathing condition in the United States.

ZACH: Now, when you say, "Obstructive and central." You say most of the people have sleep apnea, they have obstructive. What is the difference between the two of those?

DR. PIRTLE: Obstructive sleep apnea is fairly common and what happens when we fall asleep is that we relax, and that’s normal that we relax, but in some people when they sleep, the upper airway relaxes too much so that when they inhale the airway partially collapses, and you get loud snoring type sounds. The snoring in and of itself is not actually the concerning part. The concerning part is that as the airway collapses you don’t inhale normally. And so, then you don’t get adequate oxygen into the lungs, and you don’t eliminate CO2 which is sort of the two main functions of the lung. So then if you don’t breathe appropriately, the oxygen level in your bloodstream drops. Your blood pressure shoots up. It puts a strain on your heart and strain on your lungs. And it will eventually, when the apnea becomes severe enough, it will interrupt your sleep. You’ll arouse to a different level of sleep so that you can breathe. Central apnea is a little different, and it's much less common, but it involves a lack of a signal to breathe from the brain to the breathing apparatus. It is much more difficult sometimes to detect and to treat because it can be much less symptomatic, but thankfully, it's very uncommon.

ZACH:  Now, you mentioned that obstructive sleep apnea it is the most common sleep disorder of breathing in the United States. Do you have like a rough number of how many people suffer from this?

DR. PIRTLE: So, it's actually kind of surprising the -- Nobody really knows an exact number. Obviously because we don't detect it as easily as say a common process, such as diabetes. It's about as prevalent as diabetes. So, somewhere between 18 and 22 million people in the United States, and about a billion people worldwide have obstructive sleep apnea.

ZACH:  Wow, so that's over one eighth the population of the planet, right?

DR. PIRTLE: Right.

[Music plays to signal a brief interjection in the interview]

KATIE: We wondered what role does age play in sleep apnea? What we found might surprise you. Although it is more common in the elderly, or as we age, sleep apnea can develop as early in life as when one is just a newborn. It's very difficult to diagnose in extremely young children, like toddlers, since they can't communicate their symptoms. But fortunately, it's much less common in kids, though it does happen. As we age it becomes much more common, and some estimates are that 25% of adults between the age of 20 and 70 suffer from sleep apnea. Adults older than 60 are at a significantly higher risk for developing the disease. Why is this? As we age our muscles weaken, and our airways become more collapsible, the reflexes the between brain and the upper airways start to slow down, and sleep disordered breathing can occur more regularly in light sleepers, of which older adults tend to be. Sleep apnea can also increase the rate of our aging. In a study conducted by the University of Missouri School of Medicine, it was found that sleep apnea induced sleep disruptions, and lower oxygen levels during sleep promoted faster biological age acceleration, compared to the control group. However, patients who adhered to CPAP showed deceleration of aging, while the trends did not change for the control group. We'll talk more about preventative measures like CPAP later in our conversation with Dr. Pirtle.

ZACH: Loud snoring is the most well-known symptom or sign of sleep apnea. But it's more of a symptom than a root cause of what troubles could come from sleep apnea, right? It’s more like a warning sign than anything else about it, right?

DR. PIRTLE: Right, so the snoring. Sometimes a snore is just a snore. Actually, snoring in and of itself can be associated with some health problems, but it's pretty mild. But snoring with obstructive sleep apnea, as you said, is just a symptom, the real problem is dynamic airway collapse and inadequate ventilation. You know, there are a lot of symptoms that are associated with sleep apnea. Actually, probably the most common symptom is excessive tiredness, or excessive daytime sleepiness. The -- What happens when you develop an obstruction during sleep is that it disrupts your sleep pattern. You don't necessarily wake all the way to consciousness, but your sleep pattern will change. Or your brain, waves will change so that you're not getting continuous restorative sleep. You're constantly interrupted because of your sleep disordered breathing.

ZACH: It interrupts that REM sleep that we want.

DR. PIRTLE: So actually, both kinds of sleep, there's REM sleep and non-REM sleep. And in some people sleep apnea is more common in REM, and in some people sleep apnea is more common in non-REM, but it's the -- It's actually the stage two and three non-REM sleep that is the most restorative, and when that's interrupted you, you don't rest well. And you don't, you don't feel well during the day, you're tired all day. You fall asleep during common tasks, you fall asleep driving, that kind of thing.


ZACH: Concentration, that sort of thing.

DR. PIRTLE: Correct.

ZACH: Yeah, and I personally experienced, not on a regular basis, but there's probably a handful of times in my life, where I've woken up, usually when I have -- And I've always thought it's maybe because I was maybe sleeping, weird, position or something. Like, I fell asleep on the couch, and I wake up, I'm like... Like it's a very scary thing like to wake up because you feel like you can't, you know, you can't breathe or something like that. And this is something that people that have sleep apnea, that happens rather commonly.

DR. PIRTLE: Yes, it is very common with obstructive sleep apnea to have episodes where you awaken yourself with difficulty breathing or with a feeling of cessation of breathing. That can happen in the absence of sleep apnea, but it is suggestive. Other common symptoms would be waking up with a headache, waking up not feeling rested. If someone sees you stop breathing while you sleep, that is very predictive of having sleep apnea. So, if someone tells you, "You know, when you're sleeping you stop breathing." It's almost certain that you have obstructive sleep apnea. Some other symptoms at that are not as common. Interestingly enough getting up to use the restroom several times through the night is associated with a diagnosis of sleep apnea.

ZACH: Really, so what’s the connection there?

DR. PIRTLE: Yeah, so that one is not entirely clear-cut. The theory is that you wake. You don't know why you woke up. And so, your body says, "Well, maybe I needed to -- Maybe I needed to go." And so you go to the restroom, but it's very clear that those episodes decrease in frequency when a patient is discovered to have sleep apnea and initiates treatment.

ZACH: Okay, interesting, yeah, because I think we've all had those moments where we wake up and we don't know why, right? And for some people that might be your body triggering -- Obviously, you can't hear yourself snoring when you're asleep. So, you wake up, you don’t know why, but that might be why. And I guess, to get back to me for a second, since I've, you know, experienced that every now and then. That doesn’t necessarily mean -- Like if someone has that, they feel that obstruction when they wake up like, I don’t know a handful of times every now and then, does that mean they have sleep apnea? Or does it really mean like, oh, it just happened to be a random occurrence of your -- Your neck was in a weird spot or something like that, you know what I mean?

DR. PIRTLE: So, those kind of episodes can happen to anyone, and when we assess obstructive of sleep apnea, we look for severity of disease. We look at something called the apnea hypopnea index, or the number of events per hour. And so, the number of times when you breath inadequately, or you stopped breathing in an hour, and anything under five is considered normal really.

ZACH: Okay, that sounds like a lot actually.

DR. PIRTLE: Yeah, no. We all stop breathing every once in a while, while we sleep, but as long as it's not associated with symptomatology. So, if you're not excessively sleepy during the daytime or you don’t have waking headaches, you don’t have oxygen desaturation while you're sleeping. Then that's not really as concerning and then even if you have mild sleep apnea, so your apnea hypopnea index, or this, number that we look at is between 5 and 15. As long as you don't have associated symptoms, that's not really considered all that concerning.

ZACH: Now, in my research I found that, as you mentioned diabetes is connected as well as hypertension is a big connection between sleep apnea and hypertension. What is that correlation?

DR. PIRTLE: So, there are a lot of different medical problems that have a positive association with obstructive sleep apnea and just as a disclaimer, straight up front, nobody really can demonstrate a causative relationship. Right? So, we know that people with sleep apnea have these certain medical conditions, but we can't prove that’s caused by the sleep apnea. And maybe they have factors in common, but one of the more common is high blood pressure. You mentioned hypertension so, patients that have hypertension, a large percentage of them will have obstructive sleep apnea. And patients who have refractory hypertension, so they're on two drugs or more to treat their hypertension, 80% of those people will have sleep apnea. People who have congestive heart failure, 50% of patients with congestive heart failure will have obstructive sleep apnea. Diabetes is less commonly associated with sleep apnea, but untreated sleep apnea is associated with difficult to control diabetes. Heart attacks are associated with obstructive sleep apnea. Strokes, all these things are much more common in patients who have obstructive sleep apnea. What's also clear is that if we can diagnose and treat the obstructive sleep apnea, the incidents of the heart attack, and the stroke, the control -- The heart failure, those things all get much, much better.

ZACH: Now, is there a genetic or hereditary component to sleep apnea?

DR. PIRTLE: It seems to run in families, you know, demonstrating a genetic base or a genetic sequence that’s associated with sleep apnea is very difficult. So, is there a known genetic marker? No. But, is there likely a genetic component? There likely is. Though, it's very hard to say that when it's a familial association, because sometimes it's environmentally related as well, right? Because families tend to have the same habits.

ZACH: Habits, diet, that sort of thing.

DR. PIRTLE: Right so, being overweight, or having a bad diet, or smoking. Those things are associated with obstructive sleep apnea, and if, you know, if your parents had those things, you're likely to have those things, as well, or more likely.

ZACH: Gotcha. Now, you mentioned some of the more extreme worst-case scenarios for sleep apnea. But what I mean, what is the worst-case scenario for sleep apnea if it goes untreated like? It can perhaps lead to a heart attack or something like that. Like, it can be pretty serious if left unaddressed, correct?

DR. PIRTLE: People with obstructive sleep apnea have a higher incidence of sudden cardiac death. It doesn't mean that the sleep apnea caused the sudden cardiac death, but there’s certainly that association, and it's difficult to understand the physiology, and not believe that there's likely some correlation. There's likely some cause there, but we can't prove that yet. But as you've said, heart attack is much more common, especially in severe -- Moderate to severe sleep apnea. Very difficult control congestive heart failure is common in obstructive sleep apnea.

ZACH: Alright we talked about how if you snore loud doesn't really affect you personally, right? But speaking from experience, as I mentioned to Dr. Pirtle something that does affect me personally, is when I wake up and I can't breathe, and it's a very scary thing. Has this ever happened to you, Katie?


KATIE: I certainly don't think I've ever woke up gasping for air. I would say the closest I've ever come to that, and why I think this is important for you to address is because when I was sick last, I think I woke up with a really dry throat, coughing and couldn't really catch my breath ‘cause I was coughing so much. But certainly, never gasping for air though which sounds terrifying, Zach.

ZACH: Yeah, there was one time where I took a nap on my couch. And this was a few years ago, and I think this the first time it's ever happened me. And yeah, and I chalked it up to like, “Oh, I had my head on like the arm of the couch and maybe my neck was in a weird spot.” But when I woke up, I’m like... Like, I was like, “This is it. This is how I'm gonna go out.” Like, it really felt that way. As Dr. Pirtle mentioned in the conversation it's like this rush of adrenaline because you’re like, “Hey, you gotta breathe. Come on, man.” That’s your body telling you that.

KATIE: “Back to life. Come on.”

ZACH: And it's just -- It's a terrifying experience. It's not like it happens to me regularly or anything, but that's the -- I distinctly remember that first instance, and then every now and then it happens.

KATIE: What's every now and then to you though, is this like once a month, is this a few times a year?

ZACH: Maybe once a month? So, this is why I'm concerned. This is why it's a near and dear topic to me.

KATIE: Yeah, I was about to say, I would be concerned enough with even just like once a month, if it's more than once a month, I would definitely be concerned because that's you waking up. I mean, what if you’re -- What if it's happening and you don't notice like, he's talking about all these other symptoms, and just fatigue. Like, are you tired? 'Cause fatigue is just daytime sleepiness, is one of the most common symptoms.

ZACH: No, the fatigue, I don't really experience. Because again, I'm one of those people that can just go to sleep anywhere, anytime which really frustrates my wife, by the way.

KATIE: Yeah, I think that's fair.


ZACH: So, I have that going for me at least. But yeah, these are things that, with the loud snoring, with the occasional gasping for air, like, you start to see these signs and I'm like, “Oh, maybe I do have sleep apnea.” So, that in, when we come back from the break we'll talk to Dr. Pirtle about sleep studies, diagnosing sleep apnea, and ways to prevent and alleviate both sleep apnea, and its symptoms. 

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ZACH: Back to our conversation with Dr. Pirtle. Let’s talk about some treatments, some way to prevent, perhaps cure it. Is there a way to cure it? Or is it just, kind of treatment at this point?

DR. PIRTLE: So, there's no cure for obstructive sleep apnea, but there are very, very effective treatments. The most common treatment, the one that everyone has heard of, and the one that is by far the most effective, safest, easiest, best way to treat obstructive sleep apnea is something called continuous positive airway pressure or CPAP. What that involves is a snug-fitting mask, or nasal device that hooks up to a little machine that generates pressure. And it just puts a little positive pressure into the airway to open the airway up. So that when you fall asleep, and you relax, then your airway doesn't collapse, and then you breathe normally, and you ventilate well. And your oxygen level doesn't drop, and it does away with the strain on your heart, and your blood vessels. And it is very, very effective. And if we can use CPAP, it is by far the preferred therapy.

ZACH: Okay. Now, how serious does your sleep apnea have to be to get a CPAP machine?

DR. PIRTLE: So, the -- You know, I mentioned earlier that if your -- If your number of episodes was very low, it's not as concerning, but we treat people with very mild sleep apnea if they have any associated symptoms. So, if they're hyper somnolent, which is a really fancy word for really sleepy.

ZACH: Okay, I've not heard that term before.

DR. PIRTLE: They have excessive daytime sleepiness, even though their AHI is only 5, or 5 to 15. We would still treat them with CPAP and then obviously, anything above that, we treat very aggressively because the -- You know, the risk of the heart attack, and the stroke, and the congestive heart failure. All those things increases along with the severity of the sleep apnea.

ZACH: Now, in order to even see if you need a CPAP machine or something like that. Is the first step being a sleep study or?

DR. PIRTLE: So, the diagnosis of sleep apnea is sometimes difficult. I mentioned earlier, it's about as common as diabetes, right? But diabetes is easy to diagnose. You do a little blood test, and it's either there or it's not. Sleep apnea, you have to be alerted by the symptoms, and you have to have the foreknowledge to associate those symptoms with the condition. So, the diagnostic test of choice, as you said, is a sleep study, and there’re two or three different kinds of sleep studies. The gold standard is what we call a polysomnogram, which just means a whole bunch of different things, we monitor while you sleep. So, in a polysomnogram or formal sleep study, the patient comes to a sleep lab, and they apply electrodes to monitor breathing, and EKG, and brain waves, and muscle activity, and effort of breathing. They use these fancy belts that they call strain gauges that measures the effort of the breathing. And then when they get you all hooked up, and wired up, and stuck wires into your hair and everything they say, “Alright, now just go to sleep.”


But interestingly enough, most people who have obstructive sleep apnea can go sleep in those circumstances because they're chronically sleep-deprived and so, they are able to just fall asleep, and we get good data on that.

ZACH: Are they like, in a normal bed, or they gotta -- I think of sleep lab like, if somebody’s like, in a tube.

DR. PIRTLE: So, most labs these days try to have an environment that mimics a home environment. So, as an example the sleep lab we have here at Methodist Willowbrook, they have Tempur-Pedic mattresses, and a nice TV with all the cable channels. And, you know, things that you would have in your bedroom at home to make you comfortable so that you can sleep in a way that approximates what you would do at home, right. Yeah, there's no hospital beds, or we don't want you elevating the head of your bed or anything.

ZACH: Right ‘cause you wanna replicate what a typical night's sleep would be for you, right?

DR. PIRTLE: Exactly, exactly. So, there is another form of sleep study that is becoming more and more common these days, that is called a home sleep test. It is less complex than an in-lab sleep study, and it doesn't offer anywhere near as much information. But it is helpful as a screening test almost. If it is positive, it’s diagnostic, but if it is not positive, we don't even call it negative, we call it non-diagnostic. So, you can use it to detect obstructive sleep apnea, but you can't use it to rule out obstructive sleep apnea. So as an example, if a 45-year-old gentleman, who was 50 pounds overweight came to me and said, “I snore all night long, my wife says I stop breathing and I'm tired all day.” I would likely send him for a home sleep test because the chance that he has obstructive sleep apnea is very high, and we can get the information we need from the home sleep test. But if there are subtleties that come out in the history, or if the history is not plainly suggestive, then the in-lab sleep test is always the better test.

ZACH: Is that something you can get over the counter at a drugstore? Or is that something that has to be prescribed to you by a physician?

DR. PIRTLE: So, it has to be ordered by a physician. Most sleep labs can do the in-lab study, and they'll have some home sleep test equipment that they can do the home sleep test as well.

ZACH: Okay. Jumping back to that, the CPAP machine, say that you do get a CPAP machine for yourself, is this something that – Is it a case-by-case basis that you get prescribed to how many nights a week to use it? Are you supposed to use it every night? Like, what's -- For someone with a CPAP machine, what does the nightly sleep routine look like? Do you have to plug that in and hook it up every night?

DR. PIRTLE: So, the theory behind the CPAP is that you're not breathing adequately while you sleep. So, every time you go to sleep, you should put your CPAP on, not just at night, but even if you lay down and take a nap in the middle of the day you should put your CPAP on. The more you wear it, the more benefit you’ll get from it. ‘Cause if you go to sleep when you’re not wearing it then you will have episodes of oxygen desaturation, and adrenergic overload, or adrenaline spikes because you quit breathing. So, it's important to wear it as much as you possibly can.

ZACH: And the technology has evolved over the years to be a little more comfortable for users, correct?

DR. PIRTLE: That's correct. So, the new machines are nowhere near as invasive or pervasive as they were in the past. The masks are very small, very comfortable, the machines are -- Most of them around the size of Kleenex box. They’re so quiet that when you turn it on, you can't hear it running. Most people don't have trouble accommodating to the CPAP device, and in fact, in people who truly have obstructive sleep apnea, who begin treatment, many of them come back to me and said, “I'll never sleep without it again.” Because it truly makes a huge difference in how they feel, it really changes people's lives when they begin treatment for their sleep apnea. ‘Cause they've been chronically sleep-deprived for years and didn't realize it because it's just, it's insidious, right? It just – It builds up every day. They're a little more tired, a little more tired, a little more tired. And then when we break that cycle, and they get a good night's sleep, they realize how bad things have been. And most people don't stop using their CPAP once we get them comfortable with it.

ZACH: You know, that makes sense. You kinda acclimate to whatever your normal is. And then, you're so far off where you should by the time you probably get one of these machines that it's a literal breath of fresh air when you get one these CPAP machines. So, other treatments like dental, oral appliances, have you seen success from this?

DR. PIRTLE: So, there are several different other approaches to obstructive sleep apnea, and the most common secondary device, you mentioned, is a dental device. It's called a mandibular advancement device, fancy word for a mouthpiece. And what the theory is behind the mandibular advancement device, it's a two-piece mouthpiece that inserts onto the top teeth and the bottom teeth, and then it locks the bottom teeth into place, forward of where they would typically rest. So that it attempts to open the airway by physically advancing the jaw, or the mandible. Those are not as effective in obstructive sleep apnea, and are typically only recommended in people who are intolerant of CPAP. They tend to be more effective in patients that have mild obstructive sleep apnea, though occasionally, someone with severe sleep apnea, or even moderate sleep apnea will have benefit from it. It's very hard to predict who's gonna have that benefit. The drawbacks to the mandibular advancement device are first and foremost, it's not recommended as primary therapy, but it can also be associated with TMJ syndrome or pain in the jaw, and it can be associated with dental erosions or problems with your teeth.

ZACH: Now, you see a lot of other potential treatments out there like nasal strips, right? Those are more to help with snoring, not so much to help with sleep apnea, correct?

DR. PIRTLE: That's correct. So, any of these over-the-counter devices that says they can help with sleep apnea are not being truthful.

ZACH: Okay?

DR. PIRTLE: So, all the over-the-counter devices, nasal strips, the suction cup devices. All those things are helpful for snoring because sometimes snoring is at a different level, or it's a different process than obstructive sleep apnea, but real obstructive sleep apnea, there are very few things that are effective. And again, CPAP is by far the safest and most effective therapy. The grand majority of people, and I say grand majority, I mean more than 90-95%, we can get them comfortable with a CPAP device. But there are some people who have profound claustrophobia or post-traumatic stress disorder. Some people just can't seem to calibrate to the device. It's actually fairly uncommon, but it does happen. And then we have to begin to look at these secondary approaches to therapy. There are some surgical options that have been tried in past, the most common is a very complex procedure called a Uvulopalatopharyngoplasty, where they go in and take out a lot of the soft palate, and the tonsillar pillars and a little bit of the base of the tongue, just try to open the airway up and that, that doesn't really work very effectively. It can reduce the apnea hypopnea index in about half of people. And then in the people that it's effective in, half of them will have their sleep apnea return. So, it's a pretty big invasive procedure for a low effectiveness rate. The only surgery that's ever actually been shown to have a significant impact on obstructive sleep apnea is weight loss surgery. 'Cause weight loss really is a significant part of the long-term therapy for sleep apnea. So, we talked about CPAP, it is by far, the safest, easiest, cheapest, best way to treat obstructive sleep apnea. But then when we look at what risk factors are for sleep apnea, the modifiable risk factors are obesity, cigarette smoking, sometimes sleep positions. So, some people can actually improve their obstructive sleep apnea by sleeping on their side. But the modifiable things, the one that is by far the most significant is obesity, or being overweight. And so, weight loss surgery is helpful in that long-term goal. Obstructive sleep apnea, again, I continue to draw parallels to diabetes, obstructive sleep apnea is very similar to diabetes in that a person with obstructive sleep apnea, with diet, weight loss, appropriate exercise, can control their obstructive sleep apnea, though they always will have obstructive sleep apnea. Just like a diabetic can control their blood sugar with weight loss, and exercise, but they will still always be diabetic. They may not need anti-hyperglycemics, just like a person with sleep apnea may not need CPAP if they lose enough weight, though that doesn't always happen, but they still have obstructive sleep apnea.

ZACH: Yes. So, there's some tangible lifestyle changes that you can enact yourself to improve your situation.

DR. PIRTLE: Correct. So again, the most, the one that is most impactful in obstructive sleep apnea is weight gain and loss, but it's not just about weight. Even people who are in great shape can have obstructive sleep apnea, but it becomes more prominent and more likely if you're overweight.

ZACH: Sleep position thing interests me, why would sleeping on your side potentially improve your sleep apnea, as opposed to sleeping on your back.

DR. PIRTLE: So, there is an anatomical component to that and the elements of the oropharynx or the tongue, and the soft tissue fall back or relax back into the posterior pharynx and participate in that obstruction. So, it's not as simple as anatomy, but anatomy does play a role. If it were simply anatomic, there would be a surgery that would cure it every time, right?

ZACH: Yeah.

DR. PIRTLE: But position can make a difference in the collapsing forces in the upper airway.


ZACH: Oh, that makes sense. That makes sense. I think it's good to reiterate that even though you get things, like your nasal strips, or your mouth strips, or suction cups or all these things that you've mentioned that we talked about. Those can help alleviate snoring, but snoring is a symptom not a cause. And so, if you really wanna truly get to the root of it, the heart of it, you got to go deeper than just, “Oh, now I'm not snoring.” Cause you could still have the sleep apnea without the loud snoring.

DR. PIRTLE: So, if you have simple snoring, if you don't have obstructive sleep apnea and you’re snoring, some of those devices can be helpful, but if you have obstructive sleep apnea, those devices likely aren't even gonna to eliminate the snoring noise that you have.

ZACH: Oh, okay.

DR. PIRTLE: Cause the snoring noise from obstructive sleep apnea occurs deeper in the airway, it occurs where the collapse is. So, those things are not gonna help.

ZACH: Like, a simple nasal strip's not gonna help something that deep?

DR. PIRTLE: Right.

ZACH: Gotcha okay. But what about nasal spray, I've heard that people potentially use that to help with snoring.

DR. PIRTLE: So, again, sometimes a snore is just a snore. And that can happen anywhere from the tip of the nose down to the lower part of the pharynx. And so, if there is nasal congestion, or if there are nasal abnormalities, structural abnormalities, that certainly can lead to snoring. And so, decongestants or nasal sprays, things like that can alleviate snoring, but those things are not gonna help with obstructive sleep apnea. With the caveat that some patients who use nasal CPAP, and nasal CPAP is sort of the best way to use CPAP. A nasal mask is the best way to use CPAP. Sometimes we have to give them decongestants so that their CPAP mask can be effective. But they can -- Nasal decongestant in and of itself is not gonna alleviate sleep apnea. But it can eliminate snoring, if the snoring is coming from something in the nasopharynx.

ZACH: So, if you're having trouble sleeping, feeling fatigued, your partner said, “You snore really loud.” These are all potential warning signs that you might have a form of apnea, of sleep apnea, obstructive sleep apnea. So, at that point, probably go to your primary care physician, mention this to them, they can recommend you do a sleep study. That's probably the process you would recommend?

DR. PIRTLE: Absolutely, I mean that is -- So, the first step and the hardest step, many times, is recognizing that there may be a problem. So, it's good to have awareness of what those symptoms are. Snoring, excessive daytime sleepiness, gasping for air, observed apnea is the fancy word for somebody saw you stop breathing. All those things should prompt you to at least have that discussion with your doctor or seek out a sleep doctor.

ZACH: Gotcha. So, any other final words about obstructive sleep apnea?

DR. PIRTLE: Obstructive sleep apnea is very common in the United States and the potential consequences of having undiagnosed sleep apnea are very severe. So, if there is any question in your mind at all, you should seek that evaluation. If the sleep study is normal, then great. If it's abnormal then, you likely need treatment. The downside is very significant.

ZACH: Alright, well, thank you for your time today, Dr. Pirtle.

DR. PIRTLE: Well, thank you very much, I've had a blast.

ZACH: So, Katie, I’m actually gonna contact Dr. Pirtle ‘cause he offered after the conversation like, “Hey, send me an email, we can talk about this,” because I’m concerned about that I possibly have it. I don’t know if I do. I’m kind of still on the fence about it because as we talked about, just because you snore, and snore loud doesn’t mean you have sleep apnea. I think that’s a common misconception that I’m glad we could clear up in this conversation.

KATIE: Yeah, I think two points you just made there that, first of all, I, as your friend, would like you to go see Dr. Pirtle, or just somebody about the fact that you wake up gasping for air. I know the snoring, you know Dr. Pirtle made the big point about how snoring doesn’t mean it’s sleep apnea. But I think the fact that you have something, another symptom, or something like another symptom should definitely be the warning sign of, okay. And Zach, just to go in and just say like, “Okay, here's how I’m feeling. Maybe it’s nothing, and maybe it’s not sleep apnea.” And you do a sleep study, and it’s not sleep apnea, and then you know. So, really, it’s just like a peace of mind thing. I guess, I’m a person that needs peace of mind, and I’m sure your wife would also appreciate the peace of mind, and if it is something that you can manage better, she would probably also, you know, appreciate some peaceful sleep, to be honest.

ZACH: Yeah, big time. You know, speaking about other factors like weight gain, right. That first instance where I like woke up gasping for air, like, I was in the best shape of my life, right. Like, I’ve put on some weight since then so, it’s like, is it because I’ve gained weight? Is that why I’m snoring louder? Perhaps, but that might not have anything to do with sleep apnea, that just might be the normal snoring and things like that. And to that point, have you ever tried anything like nose strips, mouth strips, these other devices. I guess, if you don’t snore you never have, huh?

KATIE: Yeah, I was gonna say, I haven’t tried them, but I know people who snore a lot that have tried them. I don’t know if they worked for them, but I think again, once you go talk to your doctor and you can kind of say, it’s not sleep apnea, this is just normal snoring. I mean, they’re gonna let you know what you should try. And I wouldn’t be surprised if it’s just some strips on your nose.

ZACH: Right, right. And as Dr. Pirtle pointed out, like that might help with the surface level, but if you do indeed have sleep apnea that is not preventing any – That’s not helping counteract that, that is preventing a symptom not the cause.

KATIE: Yeah, exactly. I think that’s – To me that’s the big takeaway message is, just because you snore doesn’t mean it’s sleep apnea, but it could be sleep apnea especially if you have some of these other symptoms like the daytime fatigue, someone’s telling you’re waking up gasping for air. You feel like you’re waking up gasping for air. I think that’s when you certainly want to make sure it’s not sleep apnea because it’s not just snoring that’s the problem, you’re not getting enough oxygen at times, and there’s serious consequences of that. So, I definitely would say, anybody hesitant and that thinks they might have sleep apnea, as Zach, I would just say, like it behooves of you to just go check.

ZACH: And one other component, Katie, that I haven’t mentioned yet. Sleep apnea, does run, quote, unquote in my family. I’ve had family members that have it and have CPAP machines.

KATIE: That’s the third box checked, Zach. That’s three boxes now. The snoring, the gasping for air, the family members that also have it. I mean, again maybe you don’t have it, but why not check, you know?

ZACH: Right, you know, it’s an intimidating thing to think you think you’re gonna have to have your machine plugged in, but technology has evolved as we talked about with Dr. Pirtle to a point where it’s – look, it’s very quiet, it’s very comfortable, it’s the size of a small box, you can put it on your nightstand. It’s not this giant, you know, you look like you’re a cyborg, or something when you go to sleep. I don’t wanna feel that way, I don’t wanna look that way, but if the results help you and help whoever might be around you while you’re sleeping, I think it’s worth it.

KATIE: Yeah, I absolutely would say, I certainly wouldn’t want to be living with a health condition that’s gonna cause more problems down the line if it’s something as simple as using a CPAP machine every night. They really have come a long way, you can still turn over at night, it’s not like you have tubes, you’re gonna get like stuck in your tubes while you’re like moving over onto your side. I mean, I get it’s not, like, the most comfortable that’s ever happened to people, I’m sure, but everyone I know that uses one always talks more about how they’re getting the best sleep of their life, than about how like, “Oh, it’s uncomfortable to wear, but it’s worth it.” It’s literally just, “No, I’m finally sleeping.” So, Zach, you’re gonna make an appointment.

ZACH: You know, of all the topics we talk about on this podcast where you ask me, “Are you actually going to make a change in your life?” And I’m like, “Yeah, maybe, I’ll try.” This one I’m absolutely, am going to make a change. I’m gonna call for a sleep study and take it from there.

KATIE: Okay, that makes me happy to hear.

ZACH: Thanks Katie. Well, that’s gonna do it for us this week on the On Health podcast. And we encourage you all to go to our blog at HoustonMethodist.org/blog and to share, like, and subscribe to our podcast. New episodes drop Tuesday mornings, so until then, stay tuned and stay healthy.

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